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Thirty-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion versus those after cervical disc replacement

Niketh Bhashyam, Rafael De la Garza Ramos, Jonathan Nakhla, Rani Nasser, Ajit Jada, Taylor E. Purvis, Daniel M. Sciubba, Merritt D. Kinon, and Reza Yassari

OBJECTIVE

The goal of this study was to compare 30-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) versus those after cervical disc replacement (CDR).

METHODS

The authors used the 2013–2014 American College of Surgeons National Surgical Quality Improvement Program database. Included were adult patients who underwent first-time single-level ACDF or CDR for cervical spondylosis or disc herniation. Primary outcome measures were readmission and/or reoperation within 30 days of the original surgery. Logistic regression analysis was used to assess the independent effect of the procedure (ACDF or CDR) on outcome, and results are presented as odds ratios with 95% confidence intervals.

RESULTS

A total of 6077 patients met the inclusion criteria; 5590 (92.0%) patients underwent single-level ACDF, and 487 (8.0%) patients underwent CDR. The readmission rates were 2.6% for ACDF and 0.4% for CDR (p = 0.003). When stratified according to age groups, only patients between the ages of 41 and 60 years who underwent ACDF had a significantly higher readmission rate than those who underwent CDR (2.5% vs 0.7%, respectively; p = 0.028). After controlling for patient age, sex, body mass index, smoking status, history of chronic obstructive pulmonary disease (COPD), diabetes, hypertension, steroid use, and American Society of Anesthesiologists (ASA) class, patients who underwent CDR were significantly less likely to undergo readmission within 30 days than patients who underwent ACDF (OR 0.23 [95% CI 0.06–0.95]; p = 0.041). Patients with a history of COPD (OR 1.97 [95% CI 1.08–3.57]; p = 0.026) or hypertension (OR 1.62 [95% CI 1.10–2.38]; p = 0.013) and those at ASA Class IV (OR 14.6 [95% CI 1.69–125.75]; p = 0.015) were significantly more likely to require readmission within 30 days. The reoperation rates were 1.2% for ACDF and 0.4% for CDR (p = 0.086), and multivariate analysis revealed that CDR was not associated with lower odds of reoperation (OR 0.60 [95% CI 0.14–2.55]; p = 0.492). However, increasing age was associated with a higher risk (OR 1.02 [95% CI 1.00–1.05]; p = 0.031) of reoperation; a 2% increase in risk per year of age was found.

CONCLUSIONS

Patients who underwent single-level ACDF had a higher readmission rate than those who underwent single-level CDR in this study. When stratified according to age, this effect was seen only in the 41- to 60-year age group. No significant difference in the 30-day single-level ACDF and single-level CDR reoperation rates was found. Although patients in the ACDF group were older and sicker, other unmeasured covariates might have accounted for the increased rate of readmission in this group, and further investigation is encouraged.

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Selecting the lowest instrumented vertebra in a multilevel posterior cervical fusion across the cervicothoracic junction: a biomechanical investigation

Yaroslav Gelfand, Daniel Franco, Merritt D. Kinon, Rafael De la Garza Ramos, Reza Yassari, Jonathan A. Harris, Samantha Flamand, Joshua P. McGuckin, Jorge L. Gonzalez, Jonathan M. Mahoney, and Brandon S. Bucklen

OBJECTIVE

Posterior cervical fusion is a common surgical treatment for patients with myeloradiculopathy or regional deformity. Several studies have found increased stresses at the cervicothoracic junction (CTJ) and significantly higher revision surgery rates in multilevel cervical constructs that terminate at C7. The purpose of this study was to investigate the biomechanical effects of selecting C7 versus T1 versus T2 as the lowest instrumented vertebra (LIV) in multisegmental posterior cervicothoracic fusion procedures.

METHODS

Seven fresh-frozen cadaveric cervicothoracic spines (C2–L1) with ribs intact were tested. After analysis of the intact specimens, posterior rods and lateral mass screws were sequentially added to create the following constructs: C3–7 fixation, C3–T1 fixation, and C3–T2 fixation. In vitro flexibility tests were performed to determine the range of motion (ROM) of each group in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), and to measure intradiscal pressure of the distal adjacent level (DAL).

RESULTS

In FE, selecting C7 as the LIV instead of crossing the CTJ resulted in the greatest increase in ROM (2.54°) and pressure (29.57 pound-force per square inch [psi]) at the DAL in the construct relative to the intact specimen. In LB, selecting T1 as the LIV resulted in the greatest increase in motion (0.78°) and the lowest increase in pressure (3.51 psi) at the DAL relative to intact spines. In AR, selecting T2 as the LIV resulted in the greatest increase in motion (0.20°) at the DAL, while selecting T1 as the LIV resulted in the greatest increase in pressure (8.28 psi) in constructs relative to intact specimens. Although these trends did not reach statistical significance, the observed differences were most apparent in FE, where crossing the CTJ resulted in less motion and lower intradiscal pressures at the DAL.

CONCLUSIONS

The present biomechanical cadaveric study demonstrated that a cervical posterior fixation construct with its LIV crossing the CTJ produces less stress in its distal adjacent discs compared with constructs with C7 as the LIV. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

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The prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index on short- and long-term outcome following surgery for spinal metastases

Jessica Ryvlin, Seung Woo Kim, Mousa K. Hamad, Mitchell S. Fourman, Ananth Eleswarapu, Saikiran G. Murthy, Yaroslav Gelfand, Rafael De la Garza Ramos, and Reza Yassari

OBJECTIVE

Inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) have shown promise in predicting mortality in various types of cancer. The purpose of this study was to assess NLR, PLR, and SII in predicting 30-day mortality and overall survival (OS) among surgically treated patients with spinal metastasis.

METHODS

This was a retrospective study including 153 patients who underwent surgery for spinal metastasis between 2012 and 2022. Electronic medical records were manually reviewed, and NLR, PLR, and SII were calculated from preoperative neutrophil, platelet, and lymphocyte counts. Receiver operating characteristic curves with areas under the curve were generated to determine cutoff values. Logistic regression was used to determine the odds ratios (ORs) for 30-day mortality. The Kaplan-Meier method and Cox regression were used to determine the hazard ratio (HR) for OS limited to 5 years postoperatively.

RESULTS

Preoperative cutoff values were as follows: NLR > 10.2, PLR > 260, and SII > 2900. Overall, 35.9% (55/153) of patients had elevated NLR, 45.7% (70/153) had elevated PLR, and 30.7% (47/153) had elevated SII. The overall 30-day mortality was 8.5% (13/153). After controlling for confounders such as performance status and primary tumor type, high NLR (OR 5.20, 95% CI 1.21–22.28; p = 0.026) and SII (OR 4.92, 95% CI 1.17–20.63; p = 0.029) were associated with increased odds of 30-day postoperative mortality. The median OS time in the study population was 26 months (95% CI 12–40 months). After controlling for confounders such as Eastern Cooperative Oncology Group status, primary tumor, and hypoalbuminemia, high NLR was associated with shorter OS (HR 2.23, 95% CI 1.48–3.97; p = 0.003).

CONCLUSIONS

High preoperative NLR and SII were independently associated with 30-day postoperative mortality in this study. Elevated NLR was also found to be associated with shorter OS. The prognostic role of these metrics warrants further investigation.

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Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications

Rafael De la Garza Ramos, Christine Park, Edwin McCray, Meghan Price, Timothy Y. Wang, Tara Dalton, César Baëta, Melissa M. Erickson, Norah Foster, Zach Pennington, John H. Shin, Daniel M. Sciubba, Khoi D. Than, Isaac O. Karikari, Christopher I. Shaffrey, Muhammad M. Abd-El-Barr, Reza Yassari, and C. Rory Goodwin

OBJECTIVE

In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD.

METHODS

The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes.

RESULTS

Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18–1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16–1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46–1.98, p < 0.001), with no significant difference in inpatient mortality rates.

CONCLUSIONS

Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.

Free access

Optimizing the residency application process: insights from neurological surgery during the pandemic virtual application cycle

Robert Romano, Debraj Mukherjee, L. Madison Michael II, Judy Huang, M. Harrison Snyder, Vamsi P. Reddy, Katherine Guzman, Pamela Lane, Jeremiah N. Johnson, Nathan R. Selden, Stacey Q. Wolfe, and on behalf of the Society of Neurological Surgeons

OBJECTIVE

In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights.

METHODS

Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020–2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee.

RESULTS

Responses were received from 77 (67.0%) of 115 PAs, 119 (51.7%) of 230 program leaders, and 124 (44.3%) of 280 applicants representing geographically diverse regions. During the virtual application cycle relative to the previous year, programs received more Electronic Residency Application Service applications (mean 314.8 vs 285.3, p < 0.0001) and conducted more applicant interviews (mean 45.2 vs 39.9, p = 0.0003). More than 50% of applicants applied to > 80 programs; 60.3% received ≤ 20 interview invitations, and 9% received > 40 invitations. Overall, 65% of applicants completed ≤ 20 interviews, whereas 34.7% completed > 20 interviews. Program leaders described one 4-week home subinternship (93.3%) and two 4-week external subinternships (68.9%) as optimal neurosurgical exposure; 62.8% of program leaders found the standardized letter of recommendation template to be somewhat (47.5%) or significantly (15.3%) helpful. Applicants, PAs, and program leaders all strongly preferred a hybrid model of in-person and virtual interview options for future application cycles over all in-person or all virtual options. Ninety-three percent of applicants reported matching within their top 10–ranked programs, and 52.9% of programs matched residents within the same decile ranking as in previous years.

CONCLUSIONS

Optimizing a national strategy for the neurosurgery application process that prioritizes equity and reduces costs, while ensuring adequate exposure for applicants to gain educational opportunities and evaluate programs, is critical to maintain a successful training system.